Fungal infectionsacademic.sun.ac.za/stellmed/CourseMaterial/Annual GP...T capitis • HAIR LOSS -...

Fungal infections

Dr. W.I. Visser / KannenbergDivision of DermatologyDepartment of Medicine

Faculty of Health SciencesUniversity of Stellenbosch

Tygerberg Hospital

Objectives

1. Dermatophyte infections

2. Candida infection

3. Malassezia infections

Clinical picture & Treatment

Fungal skin infections

dermatophytes non-dermatophytes

• Yeast-like fungus – Candida albicans

• Molds

KOH

• Dermatophyte

septate hyphae

• Candida

round or oval cells

pseudohyphae

septate hyphae

Candida

Dermatophyte

If it scales scrape it!

Terms

• ‘ringworm’

• ‘tinea’

• grow only in keratin

dermatophyte

infection

stratum corneum

hair

nail

DERMATOPHYTE INFECTION

Microsporum canis

Trichophyton violaceum

Epidermophyton floccosum

T. capitis

T. barbae

T. corporis

T. cruris

T. faciei

T. manuum

T. pedis

T. unguium

DERMATOPHYTE INFECTION

OF THE SCALP

• mostly childhood

• sebum contains fungistatic fatty acids

• Trichophyton violaceum

T capitis

• HAIR LOSS - patchy

• grey patch

• yellow patch (= impetigo)

• alopecia areata – like

• black dot type

• seborrheic dermatitis – like

• kerion (abscess-like) [antibiotics / surgery]

• favus

• pustular

Favus

Kerion

Moth eaten

Grey patch

Black dot

Alopecia areata-like

IMPETIGO OF SCALP

primary impetigo vs. secondary impetigo

• head lice

• dermatophyte infection

• scabies

DERMATOPHYTE INFECTION

OF THE

FACE AND BEARD

T faciale

T barbae

DERMATOPHYTE INFECTION

OF THE

BODY

T corporis

• annular lesions with active border, red and

scaly, central clearance

• adults : from feet

• child : from scalp

T corporis

Differential diagnosis

• Dermatitis

• Psoriasis

• Dermatophyte

• Medication

• Syphilis

• T-cell lymphoma

DERMATOPHYTE INFECTION

OF THE

GROIN AREA

T cruris

• men > women

• annular lesions with active border, red

and scaly

• central clearance

• look for DF infection of feet / nails

T cruris

DERMATOPHYTE INFECTION

OF THE

HAND

T manuum

• usually unilateral

• red & scaly

• vesicopustular

• annular lesions with active border, red and scaly, central clearance

• Source : feet

T manuum

DERMATOPHYTE INFECTION

OF THE NAILS

Tinea unguium

• toenails > fingernails

• especially adults

• aspecially great toenail

• thickened

• discoloured : yellowish / white

• subungal hyperkeratosis

• onycholysis

• paronychia

T unguium

DERMATOPHYTE INFECTION

OF THE

FOOT

T pedis

• between toe’s (athlete’s foot) [swimming pool / shower]

• annular lesions with active border, red and scaly,

• central clearance

• vesicopustular

• red and scaly (mocassin)

• Diabetic patients at risk

• TWO FEET, ONE HAND!

T pedis

WOOD’S LIGHT

• Microsporum canis

• yellow-green

M. canis

TINEA INCOGNITO

• dermatophyte infection

• topical steroids

• altered appearance

• erythema with scaling and pustules

• no active border!

T incognito

‘IDE’ REACTIONS

• dermatophyte infection (athlete’s foot)

• reaction at a distance

• vesicular, papular

• immunological

• no fungi

Id reaction

Learning point

If your patients’s “asymmerical eczema” is

spreading despite local steroids

– think of a dermatophyte infection

DIAGNOSIS

• clinical

• KOH and microscopy

• culture

• skin biopsy

• therapeutic trial

Scalpel blade

Scalpel blade

KOH

Glass slide

Microscope

KOH microscopy

Treatment

localized infection

• topical imidazole (eg. clotrimazole)

- fungistatic

• topical allylamine (eg. terbinafine)

- fungicidal

Treatment

Systemic treatment for dermatophyte

infection of the scalp, onychomycosis of

many nails, and, widespread infection

elsewhere (eg. body)

TREATMENT

• scalpGriseofulvin 10 – 20mg/kg with a meal for 6 weeks

• many nailsterbinafine (Lamisil)itraconazole (Sporanox)fingernails : 6 weekstoenails : 8 - 12 weeks

• all other widespread infection

itraconazole (Sporanox)terbinafine (Lamisil)griseofulvin

Treatment

MYCETOMA

• Direct inoculation

• Soil fungi

• Deep infection

• Abscesses and draining sinuses

• GRAINS/ GRANULES

Mycetoma (Madura foot)

Treatment

• Refer

• Surgery

• Systemic therapy

Onychomycosis

• Encompasses all fungal infections of the

nail – dermatophytes/non-dermatophytes

• (nail dystrophy presentation)

CANDIDA INFECTIONS

Intertriginous candidiasis

of major flexures

Candida granuloma of

Scalp (rare)

Oral candidiasis

Interdigital candidiasis

Chronic paronychia and

nail plate

candidiasis

Genital candidiasis

Candida albicans

• topical steroids

• systemic steroids

• immunity (HIV / AIDS, malignancy, CT)

• broad-spectrum antibiotics

• DM

• warmth, friction & moisture

CandidaORAL MUCOSA

• erythema & white curd-like plaques

ANGULAR CHEILITIS (hoekstomatitis)(perlèche)

• age

• ill-fitting dentures

• Staphylococcus aureus

CHRONIC PARONYCHIA

• water immersionhousewivesbarstafffloristsfishmongers

• erythema, edema & nail dystrophy

Chronic Paronychia

BALANITIS / VULVOVAGINITIS

• poor hygiene

• pregnancy, OCP

• erythema

• small white patches

• erosions

INTERTRIGO

• = intertriginous areasincluding abdominal fat apron

• obesitypoor hygienered & scaly‘satellite’ pustules

DIAGNOSIS

• clinical

• KOH and microscopy

• culture

• skin biopsy

• therapeutic trial

TREATMENT

• nystatin (Mycostatin®)

• amphotericin B (Fungizone®)

• topical imidazole

• topical allylamine

• Lamisil® / Sporanox® po

• griseofulvin : effective Θ

• PVC / latex gloves with cotton lining

Learning points

• Alwys check the urine for sugar.

• Remember that griseofulvin has no action

against Candida.

PITYRIASIS VERSICOLOR

• Pityrosporum ovale (Malassezia furfur)

• young adults

• tropical climates

• macules with fine scaling

• hypopigmented

• hyperpigmented

• trunk and upper arms

• asymptomatic / cosmetic

• KOH & microscopy : “meatballs & spaghetti”

P versicolor

P versicolor

P versicolor

“meatballs & spaghetti”

TREATMENT• selenium sulphide shampoo (Selsun®)

• Ketoconazole shampoo (Niz® shampoo)

• topical imidazole

• ketoconazole (Nizoral®)

400mg / day x 2 days

• Sporanox®

400mg stat

or 200mg / day x 7 days

Important!

• residual hypopigmentation

1 – 2 years to repigment

• recurrence common

Learning points

• This is not a dermatophyte infection, do

not try griseofulvin or terbinafine.

• Patients think the treatment has not

worked if their pale patches do not

disappear straight away

- Warn them about this in advance.

Cryptococcus

Histoplasmosis

Sporotrichosis

What must you know

• Dermatophyte infections

• Candida

• Malassezia

• Know about systemic fungi can effect skin

Test